Provider Demographics
NPI:1093412025
Name:QUILLEN, TIMOTHY WYATT
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:WYATT
Last Name:QUILLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2216 OHIO RIVER RD
Mailing Address - Street 2:
Mailing Address - City:GREENUP
Mailing Address - State:KY
Mailing Address - Zip Code:41144-6603
Mailing Address - Country:US
Mailing Address - Phone:606-923-9155
Mailing Address - Fax:
Practice Address - Street 1:437 JAMES E HANNAH DR
Practice Address - Street 2:
Practice Address - City:SOUTH SHORE
Practice Address - State:KY
Practice Address - Zip Code:41175-9600
Practice Address - Country:US
Practice Address - Phone:606-932-3614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-09
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY008916183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist